1. Raj Woolever, MD Associate Program Director Central Maine Family Medicine Residency AAFP Family Medicine Global Health Workshop September 11, 2009

2. A Two-way Street  Growing interest among US medical students in international health  Rising numbers of international medical graduates in US residency programs

3. International Interest in All Corners  Beginnings at major universities  Johns Hopkins  MGH/Harvard  Mayo  University of Minnesota  University of Arizona  Boston University

4. International Interest in All Corners  Now not just New York to New Delhi or Boston to Bangkok

5. International Interest in All Corners  Now not just New York to New Delhi or Boston to Bangkok  But also Lewiston to Herbertpur

6. Lewiston, Maine, USA  Second largest city in Maine (45,000 residents)  Old mill town, now with many unemployed industrial workers  Surrounded by rural communities  Large population of Somali refugees (6,000)

7. Central Maine FMR  Established in 1978  7-7-7, community- based, unopposed  CMMC is a 250 bed tertiary care referral center  Rural track (2-2) at Rumford Hospital, 25 bed critical access facility

8. Herbertpur, Uttarakhand, India  Sixth largest city in Uttarakhand (20,000 residents)  Former tea plantation area, now with only one active plantation  Surrounded by rural communities and small scale agriculture  Mission hospital brings many international visitors

9. Herbertpur Christian Hospital FMR  Established in 2004  3-3-3, community- based, also OB/Gyn and Rural Surgery  HCH is a 100 bed regional hospital with an ICU  Part of the Emmanuel Hospital Association network of facilities

10. A Personal Connection  Grandson of missionaries to India  Both parents grew up in India  Rotary exchange student to India  Fulbright Fellow to Sri Lanka/work with UNICEF  Teaching at Herbertpur Christian Hospital FMR

11. A Personal Connection  Personal relationship drives connection  Residency to residency  No university structure to support relationship

12. Formalize Relationships  What is the value?  Resident to resident  Long-term connections  Facebook, e-mail  Teaching/learning environment  Different approaches to care  ACLS, ALSO, etc.

13. Formalize Relationships  What is the value?  Returning to the same location  Part of continuity/on- going care  Family medicine in action  Can support family medicine theory  Can model family medicine skills and leadership

14. Formalize Relationships  Move beyond individual connections  Introduce new CMMC faculty and residents to Herbertpur  Expand relationships with other HCH administrators and providers  Encourage institutional agreements /exchanges

15. Rural Medicine  Rural populations are underserved around the world  20% of US population is rural, but served by only 9% of physicians  Fewer resources allotted  Level of care in urban developing world has improved more quickly than rural areas

16. Rural Medicine  Medical education is an urban experience  Admission favors those from cities  Most applicants are from urban areas  Education occurs in urban tertiary care hospitals  Medical students become comfortable providing care in this setting

17. Rural Medicine  Proportion of physicians in rural areas is declining  Decreased interest in primary care  Not prepared for complex, lower tech care environment  Lower income potential  Fewer medical students from rural backgrounds, less interest in rural life

18. Rural Medicine  Rural populations have a higher disease burden  Arthritis  Asthma  Heart disease  Mental illness

19. Rural Medicine  Patients have less access to healthcare  Fewer providers  Have to travel greater distances even for primary care  Must go to urban centers for specialty care and studies

20. Wilderness Medicine  Prevention and preparation  Safety of the rescuers is first  It is still about the ABC’s  Fluids, fuel, and temperature regulation for (almost) every patient  Keep environmental factors in the forefront of decision making  Keep the full differential in mind  Think ahead

21. WIMPs  Wilderness and International Medicine Program

22. Wilderness and International Medicine  Many shared characteristics:  Often remote  Often limited resources (food, water, shelter, medical supplies/technology)  Often adverse geographical, weather, or working conditions

23. Wilderness and International Medicine  Many shared characteristics:  Often remote  Often limited resources (food, water, shelter, medical supplies/technology)  Often adverse geographical, weather, or working conditions  Often the most profound of life experiences

24. Questions?  www.cmmcfmrp.org